Understanding health care: New options begin Oct. 1

There is something good in this law for everyone in the country. It won’t work unless young healthy Americans sign up.—Dave Gessel

SALT LAKE CITY — Having allergies and asthma necessitates many trips to the doctor for 24-year-old Rachel Jackson.

Thankfully, for her own peace of mind, the University of Utah student is covered on her mother’s health insurance plan. But that will change after age 26, when the law no longer allows for it.

Jackson also has to negotiate coverage for her 3-year-old son, Charlie.

"Health insurance will always be in the top-five expenses that I will expect to pay," she said. "It’s like car insurance but more important, because it’s my own body that I have to take care of."

Because she’s always had access to it, Jackson said she has taken health care for granted. She doesn’t look forward to what's ahead, navigating and paying for health insurance by herself, but she can’t imagine life without it.

With many Americans who have either not had health insurance or are for the first time having access to it this year, Jackson is beginning to investigate her options. The 906-page Patient Protection and Affordable Care Act, passed into law in 2010, presents many changes, including increased access and affordability, but also challenges that may require assistance from local and federal advocates to sort through.

Look to Oct. 1

Starting Oct. 1, the federal health insurance marketplace will be open for enrollment, however, many believe it will be a couple weeks before information is streamlined.

Individuals seeking plans are asked to gather various information in order to apply for coverage online, including Social Security Numbers, employer and income information contained on a W-2 tax form and policy numbers for any current plan. The enrollment deadline — for coverage to begin Jan. 1 — is Dec. 15, but the marketplace will accept new enrollees until March 31.

The new law aims to help the approximately 20 percent of Americans who have had trouble getting insurance, whether it has been out of reach financially or otherwise unavailable due to health status, including preexisting conditions. The intent of the marketplace is to provide a way for consumers to compare health insurance plans and to facilitate the expansion of coverage to more people.

Essentially, every American can compare and enroll in new plans each year if desired. But not everyone will have to.

Many individuals will still be eligible or enrolled in plans offered by their employers. Large employers will likely offer similar plans this year to those they've offered before, as the federal government recently delayed penalties that would have applied.

A separate, state-run marketplace — Avenue H — is already available to small businesses and their employees. Enrollment with those plans also opens Oct. 1.

Medicare and prescriptions

Older Americans covered on Medicare also need not worry about upcoming changes, as Medicare enrollment isn't affected by further implementation of the ACA. The major thing the new law does impact for seniors is prescription drug costs, eliminating what has been called the "doughnut hole," or the gap in drug coverage that requires patients to pay the full cost for their medications.

Americans who do not obtain what is defined as "minimum essential coverage" by Jan. 1 will face a fee that increases every year. Fees are assessed per person by the Internal Revenue Service and will be paid on the following year's tax form.

People with very low incomes and others may be eligible for waivers. And individuals between jobs are allowed three months without insurance before the fee is applied.

For true reform to take hold, however, everyone must participate, said Dave Gessel, vice president of government relations and legal affairs for the Utah Hospital Association.

“There is something good in this law for everyone in the country,” he said “It won’t work unless young healthy Americans sign up.”

If everyone is insured, Gessel said the costs previously borne by providing care to the uninsured are spread more fairly. Another benefit comes from increased financial security among all Americans, as health insurance, like car insurance, protects against catastrophic and potentially financially crippling problems.

"It's sort of a conservative principle to protect yourself and society," he said.

Moving ahead

Politics aside, Gessel said that in its 2,700 pages of regulations, the health care reform law outlines provisions that intend to drive the costs of health care down, including a push toward electronic record keeping and enforcement of best practices through reimbursement incentives.

There's also a move to better transparency in the industry, allowing for easier comparison between plans and more competitive pricing.

Perhaps the most wide-reaching aspect of the new law is that individuals will no longer be rated on current health or preexisting conditions, which makes it possible for anyone to get insurance at any point of their lives.

Vanessa Watkins, of Ogden, has been lucky. She hasn't had to deal with too many health crisises in her 37 years and health care hasn't always been a priority.

"I need a roof over my head, electricity and heat, she said. "Insurance was the furthest thing down the list."

Now that it will be more available, however, Watkins intends to purchase her own plan. She's been on a limited state-funded plan for several years and hasn't used it much because it isn't accepted by many providers.

Like Jackson, Watkins wants to stay healthy to be a better mother.

Shopping for coverage

Because she's never "shopped" health insurance before, Watkins will be calling on trained navigators and certified application counselors, provided by the government, to assist her.

Three local organizations, including the Utah Health Policy Project (with the Association for Utah Community Health and United Way 2-1-1), Utah AIDS Foundation and the National Council of Urban Indian Health, have received grant money to facilitate call centers and provide assistance.

A number of community centers will also help to distribute information about the new law. Help can be found online, as well, at www.healthcare.gov.

Individual health plans from vendors throughout Utah have also set aside portions of their own websites to better explain the new law.

"The things that made it difficult for people to get insurance go away," Gessel said. "It’s a blessing for those who this is their first time having access to insurance, but the problem might be that for some people, it may still not be affordable enough."

Individuals and families who can’t afford health insurance through the marketplace may be able to apply for income-based tax subsidies to help cover insurance costs on the marketplace.

Or, depending on a decision yet to be made by Utah’s governor, many of Utah's nearly 360,000 uninsured may become eligible for an expanded version of Medicaid, taxpayer-funded insurance for low-income residents.

More than 150 stakeholders have been meeting this summer to discuss the prospects of such an expansion in the state, intending to inform the governor prior to his decision, which he has said is expected before the 2014 Legislative Session.

State agencies involved in accommodating the ACA will present a final update to lawmakers prior to the Oct. 1 marketplace opening, during a Health Reform Task Force committee meeting.